股骨颈骨折

,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二层,第三层,第四层,第五层,*,*,股骨颈骨折 (femoral neck fracture),1,定义：股骨头下至股骨颈基底部之间的骨折,特点：1，常见，约3.58%,2，老年，尤以女性较多（骨质疏松）,3，不愈合率1020（剪力较大），坏死率2040（血供不良）,老年人：多为间接暴力引起低能量损伤。,青壮年：则由直接暴力致伤高能量损伤。,2,110140，平均127 。,140 髋外翻,110 髋内翻,Anatomy,颈干角,股骨颈长轴线与股骨干纵轴线之间的夹角,3,前倾角,股骨颈的长轴与股骨的冠状形成的角度,正常为1215,Anatomy,4,小凹动脉：闭孔动脉分支，股骨头圆韧带，1/20,股骨干滋养动脉升支,关节囊外动脉环：旋股内、外侧动脉的分支在股骨颈基底部形成动脉环，是,主要血液供给来源,， 2/3 4/5,Anatomy,股骨头的血供,5,股骨头的血供,Anatomy,旋股内侧动脉损伤是导致股骨头缺血性坏死的主要因素。,股骨颈囊外动脉环紧贴股骨颈表面，因此在股骨颈骨折移位时易发生损伤。,6,按骨折部位,头下型,经颈型,基底型,骨折类型及移位,骨折线越接近于股骨头，骨折近端血供越差，发生股骨头却学坏死的可能性也越大,7,按X线表现,（Pauwels分类）,骨折线与双侧髂嵴连线（水平线）所成的角度,角度越大，剪式应力越大，骨折断端间接触面积越小，骨折越不稳定。,骨折类型及移位,8,按X线表现,外展型：,Pauwels角 30,稳定,中间型：,30, Pauwels角50,不稳定,骨折类型及移位,9,按移位程度,（Garden分类）,按移位程度：,型：不完全骨折,型：完全骨折，无移位,型：完全骨折，部分移位,型：完全骨折，完全移位,骨折类型及移位,10,临床表现及诊断,病史,：外伤史,体征：,1.畸形：外旋畸形45 60。,2.疼痛：局部压痛，轴向叩击痛阳性。,3.患肢短缩：大转子上移,11,患肢短缩,Bryant三角底边缩短,（平卧位）,股骨大转子顶端在Nelaton线之上,（侧卧位）,12,影像学检查,X片：骨盆正位，髋关节正侧位,螺旋CT三维重建,MRI：隐匿性骨折,13,老年女性，轻微外伤史，左髋疼痛，仍可负痛行走。,X片：股骨颈的下方有很细小的硬化区,MRI：股骨颈线性信号减弱,诊断：股骨颈骨折,Femoral Neck Fracture,14,与转子间骨折的鉴别,股骨颈骨折,股骨转子间骨折,外旋角度,4560,90 ,局部肿胀,常无明显肿胀,肿胀明显,瘀斑,少见瘀斑,常见瘀斑,15,治疗,治疗方案选择取决于,1.,骨折部位,2.,骨折移位程度,3.病人年龄,16,保守治疗,：无明显移位的外展,“嵌插”,型骨折或患者 不能耐受手术,牵引或防旋鞋：卧床812周，3月后扶拐不负重下地，6月弃拐行走。,17,保守治疗,骨折在早期有移位的可能，需定期复查床旁X片，如骨折有移位，股骨头缺血坏死的危险性随之增加，需改为手术治疗。因此也有人对此类骨折强调尽早手术，内固定治疗，特别是年轻病人和活动较多的老年人。,保守治疗期间注意患者的护理，预防褥疮、坠积性肺炎、泌尿道感染等严重并发症。,18,手术治疗：,移位不稳定骨折,内固定：全身情况稳定，没有慢性疾病，有较高功能要求，骨质治疗较好的患者,人工关节置换术,：65岁，有慢性疾病，骨质条件不佳，股骨头下型骨折，依从性差的患者,19,内固定：,电视X光机（C臂）下，采用闭合或开放复位内固定。在内固定术之前先行手法复位，证实骨折断端解剖复位后再行内固定术。,1，,滑动式内固定,2，,加压式内固定,20,1 屈髋及至90，沿股骨干纵轴向上牵引；2 内旋、外展患肢,3 保持内旋外展，将下肢伸直； 4 骨折复位后，下肢不外旋,21,内固定,滑动式内固定：固定钉可在套筒内滑动，早期承重更利于骨折端的嵌插。,Smith-Petersen三刃钉,破坏血运 无菌坏死,无加压作用 骨不连,22,内固定,加压式内固定,固定牢靠，减少对周围软组织的损伤，减少对股骨头血供的破坏。,23,滑动加压螺钉（DHS),24,加压式内固定,25,加压式内固定,26,植骨内固定,固定骨折同时植骨：,游离植骨,带蒂植骨：缝匠肌肌骨瓣、股方肌肌骨瓣、旋髂深动脉骨瓣的骨移植术。,27,人工关节置换术,老年人头下型骨折、陈旧性骨折、骨折不愈合或股骨头缺血性坏死。,人工全髋关节置换,人工股骨头置换,28,人工股骨头置换(半髋关节）,29,人工,全髋关节置换（全髋关节）,30,展望,随着人民生活水平的提高，人均寿命的延长，我国正逐渐进入老龄化社会，股骨颈骨折的发病率会逐渐增加，如何更好的对其进行治疗，最大限度避免股骨头缺血坏死，促进患者的功能恢复是摆在每一个骨科医生面前的严峻的挑战，但同时也是一次机遇 ,广阔天地，大展宏图！,31,Thanks,Thanks,32,EQ$5htFS&6ivHT*8kwJV)9myKW+bnzMY0cpBN#2eqDP!3gsEQ%5htGS&6jvHU(8kxJV)amyKX+bnAMY1dpBO#2erDP!4gsER%5huGS*7jvIU(8lxJV-amyLX+coAMZ1dpCO#2frDP$4gsFR%6iuGT*7jwIU(9lxJW-anzLX0coANZ1dqCO#3frDQ$4htFR&6iuHT*7kwIU)9lxKW-bnzLY0coBNZ1eqCO!3fsEQ$5htFS&6ivHT*8kwIV)9myKW+bnzMY0cpBNZ2eqDP!3gsEQ%5htGS&6jvHT(8kxJV)amyKX+bnAMY0dpBO#2erDP!4gsER%5huGS&7jvIU(8lxJV-amyLX+boAMZ1dpCO#2frDP$4gsFR%5iuGT*7jwIU(9lxJW-amzLX+9lxJW-amzLX+coAMZ1dqCO#3frDQ$4gtFR%6iuGT*7kwIU)9lxKW-anzLX0coBNZ1eqCO!3frEQ$4htFR&6ivHT*8kwIV)9lyKW-bnzMY0cpBNZ2eqCP!3fsEQ$5htGS&6jvHT(8kwJV)9myKX+bnAMY0dpBN#2eqDP!3gsER%5huGS&7jvHU(8kxJV)amyLX+boAMY1dpBO#2erDP$4gsFR%5iuGS*7jvIU(8lxJW-amzLX+coAMZ1dpCO#3frDQ$4gtFR%6iuGT*7jwIU)9lxKW-anzLX0coANZ1eqCO!3frEQ$4htFR&6iuHT*8kwIV)9lyKW-bnzLY0cpBNZ2eqCP!3fsEQ$5htFS&6jvHT(8kwJV)9myKW+bnzMY0dpBN#2eqDP!3gsEQ%5huGS&7jvHU(8kxJV)amyKX+boAMY1dpBO#2erDP!4gsFR%5iuGS*7jvIU(8lxJV-amzLX+coAMZ1dpCO#2frDQ$4gtFR%6iuGT*7jwIU(9lxKW-anzLX0coANZ1dqCO!3frEQ$4htFR&6iuHT*7kwIV)9lyKW-bnzLY0coBNZ1eqCP!3fsEQ$5htFS&6ivHT(8kwJV)9myKW+bnzMY0cpBN#2eqDP!3gsEQ%5htGS&7jvHU(8kxJV)amyKX+bnAMY1dpBO#2erDP!4gsER%5iuGS*7jvIU(8lxJV-amyLX+coAMZ1dpCO#2frDP$4gtFR%6iuGT*7jwIU(9lxJW-anzLX0coANZ1dqCO#3frDQ$4htFR&6iuHT*7kwIU)9lyKW-bnzLY0coBNZ1eqCO!3fsEQ$5htFS&6ivHT*8kwJV)9myKW+bnzMY0cpBNZ2eqDP!3gsEQ%5htGS&6jvHU(8kxJV)amyKX+bnAMY0dpBO#2erDP!4gsER%5huGS*7jvIU(8lxJV-amyLX+boAMZ1dpCO#2frDP$4gsFR%5iuGT*7jwIU(9lxJW-amzLX0coANZ1dqCO#3frDQ$4gtFR&6iuHT*7kwIU)9lxKW-bnzLY0coBNZ1eqCO!3frEQ$5htFS&6ivHT*8kwIV)9myKW+bnzMY0cpBNZ2eqCP!3gsEQ%5htGS&6jvHT(8kxJV)amyKX+bnAMY0dpBN#2erDP!4gsER%5huGS&7jvHU(8lxJV-amyLX+boAMY1dpCO#2frDP$4gsFR%5iuGS*7jwIU(9lxJW-amzLX+coANZ1dqCO#3frDQ$4gtFR%6iuHT*7kwIU)9lxKW-anzLY0coBNZ1eqCO!3frEQ$4htFS&6ivHT*8kwIV)9lyKW+bnzMY0cpBNZ2eqCP!3fsEQ%5htGS&6jvHQ$5htFS&6jvHT(8kwJV)9myKW+bnAMY0dpBN#2eqDP!3gsEQ%5huGS&7jvHU(8kxJV)amyLX+boAMY1dpBO#2erDP!4gsFR%5iuGS*7jvIU(8lxJW-amzLX+coAMZ1dpCO#2frDQ$4gtFR%6iuGT*7jwIU)9lxKW-anzLX0coANZ1dqCO!3frEQ$4htFR&6iuHT*7kwIV)9lyKW-bnzLY0coBNZ2eqCP!3fsEQ$5htFS&6ivHT(8kwJV)9myKW+bnzMY0dpBN#2eqDP!3gsEQ%5htGS&7jvHU(8kxJV)amyKX+boAMY1dpBO#2erDP!4gsER%5iuGS*7jvIU(8lxJV-amzLX+coAMZ1dpCO#2frDP$4gtFR%6iuGT*7jwIU(9lxJW-anzLX0coANZ1dqCO#3frEQ$4htFR&6iuHT*7kwIU)9lyKW-bnzLY0coBNZ1eqCP!3fsEQ$5htFS&6ivHT*8kwJV)9myKW+bnzMY0cpBN#2eqDP!3gsEQ%5htGS&6jvHU(8kxJV)amyKX+bnAMY1dpBO#2erDP!4gsER%5huGS*7jvIU(8lxJV-amyLX+boAMZ1dpCO#2frDP$4gsFR%6iuGT*7jwIU(9lxJW-amzLX0coANZ1dqCO#3frDQ$4htFR&6iuHT*7kwIU)9lxKW-bnzLY0coBNZ1eqCO!3fsEQ$5htFS&6ivHT*8kwIV)9myKW+bnzMY0cpBNZ2eqDP!3gsEQ%5htGS&6jvHT(8kxJV)amyKX+bnAMY0dpBN#2erDP!4gsER%5huGS&7jvIU(8lxJV-amyLX+boAMY1dpCO#2frDP$4gsFR%5iuGT*7jwIU(9lxJW-amzLX+coANZ1dqCO#3frDQ$4gtFR&6iuHT*7kwIU)9lxKT*7kwIU)9lxKW-anzLX0coBNZ1eqCO!3frEQ$4htFR&6ivHT*8kwIV)9lyKW-bnzLY0cpBNZ2eqCP!3fsEQ$5htGS&6jvHT(8kwJV)9myKW+bnAMY0dpBN#2eqDP!3gsER%5huGS&7jvHU(8kxJV)amyLX+boAMY1dpBO#2erDP$4gsFR%5iuGS*7jvIU(8lxJW-amzLX+coAMZ1dpCO#3frDQ$4gtFR%6iuGT*7jwIU)9lxKW-anzLX0coANZ1dqCO!3frEQ$4htFR&6iuHT*8kwIV)9lyKW-bnzLY0coBNZ2eqCP!3fsEQ$5htFS&6jvHT(8kwJV)9myKW+bnzMY0dpBN#2eqDP!3gsEQ%5huGS&7jvHU(8kxJV)amyKX+boAMY1dpBO#2erDP!4gsFR%5iuGS*7jvIU(8lxJV-amzLX+coAMZ1dpCO#2frDP$4gtFR%6iuGT*7jwIU(9lxKW-anzLX0coANZ1dqCO#3frEQ$4htFR&6iuHT*7kwIV)9lyKW-bnzLY0coBNZ1eqCP!3fsEQ$5htFS&6ivHT(8kwJV)9myKW+bnzMY0cpBN#2eqDP!3gsEQ%5htGS&7jvHU(8kxJV)amyKX+bnAMY1dpBO#2erDP!4gsER%5huGS*7jvIU(8lxJV-amyLX+coAMZ1dpCO#2frDP$4gsFR%6iuGT*7jwIU(9lxJW-anzLX0coANZ1dqCO#3frDQ$4htFR&6iuHT*7kwIU)9lyKW-bnzLY0coBNZ1eqCO!3fsEQ$5htFS&6ivHT$5htFS&6ivHT*8kwIV)9lyKW+bnzMY0cpBNZ2eqCP!3fsEQ%5htGS&6jvHT(8kwJV)amyKX+bnAMY0dpBN#2eqDP!4gsER%5huGS&7jvHU(8lxJV-amyLX+boAMY1dpBO#2frDP$4gsFR%5iuGS*7jwIU(9lxJW-amzLX+coAMZ1dqCO#3frDQ$4gtFR%6iuHT*7kwIU)9lxKW-anzLX0coBNZ1eqCO!3frEQ$4htFR&6ivHT*8kwIV)9lyKW-bnzMY0cpBNZ2eqCP!3fsEQ$5htGS&6jvHT(8kwJV)9myKX+bnAMY0dpBN#2eqDP!3gsER%5huGS&7jvHU(8kxJV-amyLX+boAMY1dpBO#2erDP$4gsFR%5iuGS*7jvIU(9lxJW-amzLX+coAMZ1dpCO#3frDQ$4gtFR%6iuGT*7jwIU)9lxKW-anzLX0coANZ1eqCO!3frEQ$4htFR&6iuHT*8kwIV)9lyKW-bnzLY0cpBNZ2eqCP!3fsEQ$5htFS&6jvHT(8kwJV)9myKW+bnAMY0dpBN#2eqDP!3gsEQ%5huGS&7jvHU(8kxJV)amyLX+boAMY1dpBO#2erDP!4gsFR%5iuGS*7jvIU(8lxJV-amzLX+coAMZ1dpCO#2frDQ$4gtFR%6iuGT*7jwIU(9lxKW-anzLX0coANZ1dqCO!3frEQ$4htFR&6iuHT*7kwIV)9luHT*7kwIU)9lyKW-bnzLY0coBNZ1eqCO!3fsEQ$5htFS&6ivHT*8kwJV)9myKW+bnzMY0cpBNZ2eqDP!3gsEQ%5htGS&6jvHT(8kxJV)amyKX+bnAMY0dpBO#2erDP!4gsER%5huGS&7jvIU(8lxJV-amyLX+boAMZ1dpCO#2frDP$4gsFR%5iuGT*7jwIU(9lxJW-amzLX0coANZ1dqCO#3frDQ$4gtFR&6iuHT*7kwIU)9lxKW-bnzLY0coBNZ1eqCO!3frEQ$5htFS&6ivHT*8kwIV)9lyKW+bnzMY0cpBNZ2eqCP!3gsEQ%5htGS&6jvHT(8kwJV)amyKX+bnAMY0dpBN#2erDP!4gsER%5huGS&7jvHU(8lxJV-amyLX+boAMY1dpCO#2frDP$4gsFR%5iuGS*7jwIU(9lxJW-amzLX+coANZ1dqCO#3frDQ$4gtFR%6iuHT*7kwIU)9lxKW-anzLX0coBNZ1eqCO!3frEQ$4htFS&6ivHT*8kwIV)9lyKW-bnzMY0cpBNZ2eqCP!3fsEQ%5htGS&6jvHT$5htFS&6jvHT(8kwJV)9myKW+bnAMY0dpBN#2eqDP!3gsEQ%5huGS&7jvHU(8kxJV)amyLX+boAMY1dpBO#2erDP!4gsFR%5iuGS*7jvIU(8lxJV-amzLX+coAMZ1dpCO#2frDQ$4gtFR%6iuGT*7jwIU(9lxKW-anzLX0coANZ1dqCO!3frEQ$4htFR&6iuHT*7kwIV)9lyKW-bnzLY0coBNZ2eqCP!3fsEQ$5htFS&6ivHT(8kwJV)9myKW+bnzMY0dpBN#2eqDP!3gsEQ%5htGS&7jvHU(8kxJV)amyKX+bnAMY1d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